Haemorrhage control of the pre-hospital trauma patient

Haemorrhage following major injury remains the most common potentially preventable cause of traumatic death with exsanguination typically occurring within three hours of injury. Key to improving outcomes is a “care bundle” of measures to facilitate early diagnosis, rapid haemorrhage control, systemic and topical haemostatic support and short scene times [1]. The last decade has seen a paradigm shift in treatment strategies and transfusion algorithms [2] with an emphasis on haemostatic or damage control resuscitation (DCR). A key objective of this proactive and empiric approach to transfusion is to directly target Acute Traumatic Coagulopathy (ATC) which itself is associated with a four-fold increase in mortality and poor patient outcomes. This article will focus only on advanced interventions without further discussion of the fundamentals of pre-hospital haemorrhage control i.e. oxygenation, intravenous or intra-osseous assess, pelvic and limb splints and splinting of the facial skeleton. Identification of major haemorrhage must be performed as part of the initial on-scene assessment. Good clinical acumen and a high index of suspicion remain important diagnostic tools. Point of care measures of coagulation are of limited value in patients with major haemorrhage (low haematocrit). The utility of these handheld devices, in their current design, is confined to patients taking warfarin who have suspected traumatic brain injury and where reversal with prothrombin complex concentrate is indicated. Pre-hospital use of ultrasound, solely for diagnostic purposes, remains an area of controversy. Critiques argue it adds little additional information and may delay transfer to hospital for definitive haemorrhage control. An immediate priority is to localise any sites of external haemorrhage and provide direct control where possible with compression. Foley catheters inserted into a wound track, inflated and then retracted to the skin edge are good adjuncts for junctional injuries e.g. neck stab wound. Topical haemostatic dressings e.g. Celox impregnated gauze or granules are able to augment clot formation and can be applied into cavities where haemorrhage may be difficult to control directly. The use of limb tourniquets is now well established in combat medicine and has been shown to save lives particularly when applied before the onset of shock. Complications i.e. nerve damage are rare when tourniquets are applied correctly. The Eastern Association for the Surgery of Trauma (EAST) has recently published guidelines advocating their use in civilian patients for the management of penetrating lower extremity arterial trauma [3]. Radical interventions for control of life-threating haemorrhage include prehospital thoracotomy (PHT) for cardiac tamponade and (theoretically) resuscitative endovascular balloon occlusion of the aorta (REBOA) for major torso bleeding. PHT for penetrating trauma is an established intervention in a physician-led EMS system and is associated with survival rates of 18% in selected patient groups. Relief of tamponade with control of cardiac injury is the primary objective of PHT and can be achieved with minimal equipment – scalpel, Spencer Wells forceps, heavy scissors or Gigli saw, rib retractor and sutures or skin stapler. During PHT other manoeuvres such as manual compression (or clamping) of the descending aorta to arrest abdominopelvic haemorrhage and control of lung hila to treat great vessel injuries may be of benefit but all efforts should be focused on rapid transit to hospital for definitive surgical management. REBOA describes the insertion of an endovascular balloon into the femoral artery (under ultrasonic guidance) which is advanced into the aorta and then inflated to control distal haemorrhage. It has been successfully used in the Emergency Department (ED) with and without image intensifiers depending on the aortic zone of Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK Davenport Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22(Suppl 1):A4 http://www.sjtrem.com/content/22/S1/A4